LIBRARY OF CONGRESS 




021 623 836 9 ^ 




HoUinger Corp. 
pH 8.5 



RC 182 
.S2 B5 
Copy 1 



STATISTICS 



OF THE 



PRESENT EPIDEMIC OF SCApT FEVER 



COMPILED AND ARRANGED BY 



S. M. BEMZB^, M. 



4- 




Prom "The New Orleans Medical and Su^ieal Journal," July, 1876. 




STATISTICS OF THE PRESENT EPIDEMIC OF SCARLET 
FEVER IN NEW ORLEANS. 



COLLECTED AND ARKANGED BY 

M. BEMISS, M.D. 



In the present paper, and in those of a similar character re- 
lating to other diseases, which are expected to follow it, the 
writer will appear in the character of a reporter rather than that 
ot an essayist. A different course would fail in doing justice 
to those who observe and furnish the facts, which it is my desire 
simply to compile and arrange. * Still, whenever it shall appear 
to the advantage of the subject, I shall not hesitate to present 
collateral facts, or to make remarks which occur to my mind, 
tending to elucidate more clearly those truths which carefully 
gathered statistics always reveal. 

On the 6th of May, two hundred printed blanks were distri- 
buted among the physiolftns of ISTew Orleans, requesting infor- 
mation in regard to caitfes of scarlet lever observed during the six 
months ending 30th of the present year. The period 

designated in the circular comprises the six months beginning 
with November, 1875, and ending with April 30th, 1876. The 
epidemic prevalence of scarlatina in this city dates to a time 
anterior to November 1st, 1875. From January 1st, 1875, to 
May 31st, inclusive, eight deaths were reported as having been 
due to scarlet fever. From June 1st to October 31st, the monthly 
returns of scarlet fever deaths were as follows: June, 8j July, 
20; August, 21; September, 28; October, 18. It seemed to the 
writer quite a necessity that the statistics called for should be 
reatri(;ted to a shorter period than that of the whole epidemic, 
for two reasons : first, that greater accuracy might be secured 
by limiting the calls for rei)orts to the six months just expired; 
second, that some i^ositively defined term of observation should 



1876 1 Bemiss — Statistics of Scarlet Fever in New Orleans. 



37 



be noted, that comparisons with the reports of the Board of 
Health might be made useful in determining some important 
questions connected with our subject of statistical study. These 
are the causes which induced the reporter to limit the call for 
statistics to the six months just elapsed. 

The responses made to our circular have been sufficiently 
general to afford encouragement for the future of this method of 
study, and at the same time to authorize interesting conclusions 
relating to the present subject. The blanks returned embraced 
C^i^ an aggregate of This is a return of 1 in every ;;^cases 3. ^(JL 

of scarlet tever which have occurred in this city within the 
limits of the time designated in the circulars. The following is 
the process of computation by which an estimate is reached. 
The mortality exhibited by the statistics presented herein is 1 
^ in every 15.87 cases. The number of deaths occurring from 
scarlet fever as returned to the Board of Health for the six 
months designated in the calls for statistics, is 134. This num- 
ber multiplied by 15.87, yields 2126 as the estimated number of 
cases occurring in this city during the term of investigation. 

One who has been engaged as extensively in the study of 
medical statistics as the present reporter, acquires a feeling of 
respect and veneration for those statistics which exhibit inherent 
evidences of truth. The experienced statistician has but little 
difficulty in discovering whether the items returned to him have 
been carefully or loosely gathered. There is one great law of 
statistics, whose application to their study proves the correct- 
ness or falsity of all considerable aggregates. This law is based 
upon the essential predicate, that, in every mass of medical 
statistics made up by summing together individual reports, the 
majority of the individuals reporting will furnish reliable facts. 
'If under any circumstances, a minority of the reporters are either 
careless or unfaithful in making up their returns, we have only 
to go on increasing our volume of statistics until the errors re- 
lating to the minority are hidden by the preponderating mass of 
facts furnished by the majority. It hence follows that, as soon 
as the medical statistician has gathered a sufficient number of 
facts, he has a safe criterion b^^ which to measure eacli individual 
group which enters into the aggregate. 

But the experienced statistician has another equally legiti- 
mate mode of testing statistics. This is, to select several groups, 
however small, which from the character of the reporters can be 



38 



Oriffinal Commttnications. 



[July, 



assumed to be strictly correct, aod construct of these a standard 
by AYliich to measure the whole mass, both seriatim and in 
gross. Both of these modes of test have been applied to the 
statistics herein presented; and it is due to the contributors to 
state that, in only one single instance, was there so consider- 
able a departure from the mathematical uniformity of the re- 
mainder as to invite even the slightest cri:icism. This disturb- 
ance of harmony related to the very small death-rate the group 
in question exhibited. This group is included in the report, and 
the results are not appreciably altered by its incorporation. In 
' truth, Eifaiky individual practitioners can recall experiences in 
times of epidemic prevalence, when^ without claiming superior 
skill, or being able to define in what, if any, particular exercise 
of virtue, their superior success rested, they were still able to 
congratulate themselves upon a death-rate far below that of 
their surrounding professional friends. 

While, in perfect fairness to my contributors, I consider these 
prefatory remarks proper and called for, I shall not hesitate to 
vouch for the accuracy of the results and general conclusions 
appearing in the following pages. 

I shall arrange the statistics for their critical study under 
' headings corresponding with those of the circulars upon which 
they have been returned. The following table exhibits in a 
condensed manner, the facts collected under headings 1» 2 and 
3, of the circular, and at the same time has a column added 
which is designed to show an estimate of the whole number of 
eases, with results, which actually occurred in the city during 
the six months ending April 30th. The process adopted in this 
computation has been previously explained. 



Table I. • 



Actually lie- 
ported. 



Number Esti- 
mated. 



Percentage. 



1 — Number of cases for six mouths, 



2 — liecovered, without Sequl.i 



3 — Died. In primary attack 



Total Deaths 



No statement as to S'Kiuelio 



Simple Fonn 

Anginose Form 

Malignant Form 

Irregular Form 

Not plasHiKl as to Form 



ending April 30th, 1876 



From Scqu<'I:r; 



with 8<'quoli 



587 
377 
177 
.".8 
10 
45 
273 
07 
180 
20 
17 
37 



2126 
1363 
423 
137 
36 
103 
988 




651 
72 
(il 

134 



27.62 
64.22 
19.93 
6.47 
1.70 
7.66 



3. 40 
2.8& 
6.30 



1876] BmuSB-- Statistics of Scarlet Fever in New Orleans. 



39 



The percentages in this table have reference to the aggregates 
in column 1, with the exception of that at the head of the 
column, which exhibits the percentage of the estimated number 
of cases which were actuallj^ reported. 

1 — JSfuniber of Gases. Our records of the medical history of 
this city afford very meagre accounts of the prevalence of scarlet 
fever, whether in endemic or epidemic form. I think, however, 
that it may be safely assumed that scarlet fever germs are not 
infrequently entirely extinct here, a condition which seldom or 
never obtains in equally large centres of population situated in 
our more Northern States, or in Europe. Minor, in a very in- 
teresting paper on Scarlet Fever in the United States, ventures 
to formulate certain propositions, some of which directly touch 
this locality. Those of his propositions necessary to be men- 
tioned in this connection are: "No. 3. Another zone of compara- 
tive immunity in the western hemisphere extends from 30^ to 
35^ north latitude. 4. In times of pandemics, occasional epide- 
mics occur at points within the zone of comparative immunity." 
The very important investigations of Prof. Ohaille into the pre- 
valence of various diseases in this city do not sustain Dr. Minor's 
third proposition, in so far as we are concerned. During a 
period of thirteen years, divided in three series, as follows, 1856 
to 1860 inclusive, 1863 to 1865 inclusive, 1866 to 1870 inclusive, 
scarlet fever caused 1038 deaths in this city. Admitting a mor- 
tality rate during all these periods identical with that pertain- 
ing to the present epidemic, 16608 cases must have occurred, to 
have given the above stated number of deaths. The year 1864 
seems to have been one of decided epidemic violence, since 200 
deaths are reported. In 1871 five deaths were ascribed to scarlet 
fever: in 1872, three deaths; in 1873, three deaths; in 1874, four 
deaths; in 1875, one hundred and forty-four deaths. We must 
be cautious in declaring any population to enjoy immunity from 
scarlet fever, even though for a number of years few or no cases 
are observed. For 21 years, 1809 to 1829, the number of deaths 
caused by scarlet fever in Philadelphia was 108. For five con- 
secutive years of this period, not a death was occasioned by 
this disease. We all know, however, that Philadelphia has suf- 
fered under severe epidemics of scarlet fever. 



Forms of the Disease Reported. One principal object in making 



40 



Original Communications, 



[Jniy. 



the effort to obtain a classification of the cases reported, which 
shoiiM conform to that usually adopted in the text-books, was 
to ascertain whether any special relation existed between either 
form and the occurrence of sequelae. Such is the erratic nature 
of scarlet fever, that its symptomatic phenomena vary with dif- 
ferent epidemics, and the classification of one visitation may be 
quite reversed in the ratio of prevalence or inteusity of the re- 
spective forms. These facts tend to destroy the utility of such 
information, in so far as the primary attacks are concerned. 
But if it can be ascertained that some clinical form of primary 
symptoms is more liable than others to sequel£e, it is a very im- 
portant practical gain, since we become admonished of tlie 
approach of a danger which is susceptible of prevention. 

The mortality rate of primary attack can be safely assumed to 
depend upon the ratio of simple cases attending any given epi- 
demic. In this declaration I do not lose sight ot the proper 
signification of the word ''simple,'' as used to designate a clinical 
form of scarlet fever. It does not imply mitigation in the severity 
of symptoms so much as it imi)lies conformity to t.ype, and regu- 
larity^ of clinical career. A simple case may therefore be an 
intensely violent case, and yet no fatal impingement of morbid 
action upon a particular structure or apparatus is likely to occur, 
because of its equable distribution throughout the system. I 
think the study- of the classification by forms afforded by Table 
I. interesting, however little practical benefit may accrue from 
it. Under the heading "Irregular Form," some interesting tacts 
are reported which will appear more properly among clinical 
observations, instances have been reported of the co- 

existence of scarlatina and rubeola, although both of these erup- 
tive fevers have been epidemic during the latter half of the 
I^eriod of research. 

2 — Recovered laitJiout Sequel ce— Recover ed icith Sequelct. Quite a 
number of interesting tacts have been reported under these cap- 
tions, which will appear in extenso under headings Nos, 4 and G. 

3 — Died (a) in Brimary attack, (b) from Sequelw, Tlie mortality 
rate of various scarlatina epidemics is eminently a shifting one. 
According to Thomas (Ziemssen's Cyclopedia, Vol. II.), *'Epidc^ 
mics where the mortality is below 10 per cent, may be regartleil 
as benign epidemics, comparatively si>eaking.^^ Measured by 



1876J Bemiss — Statistics of Scarlet Fever in New Orleans. 41 



this standard, our late epidemic has proved a mild one. The 
aggregate mortality rate per cent, has been 6.30 My own con- 
victions are, that a more positive mode of testing various epi- 
demics in respect to mildness or violence of character, is to 
measure them by the rate per cent, of deaths occurring in pri- 
mary attacks. Intensity of epidemic force, increased personal 
receptivity, or weakened personal resistance to epidemic attacks, 
are the factors which concur in the production of the most viru- 
lent visitations of zymotic disease. Either, or all ot these factors 
tend to the production of fatal results in a speedy manner; con- 
sequently, short duration of fatal cases is a correct measure of 
violence of attacks. The ratex^er cent, of deaths during primary 
S / attacks is ^.^0; that due to sequelse is 2.89. These percentages 
^ are very probably smallijr than those marking scarlet fever 
epidemics in the more northern cities of the United States. 
Smith (Diseases of Children, Third Edition) says: ''The mor- 
tality rate varies greatly in difterent epidemics. In epidemics 
of a mild type, the mortality is sometimes not more than one in 
twelve, and the ratio may be less; whereas, if a severe form is 
prevailing, not more than one recovers in every two, three, or 
four." Meigs & Pepper observed 274 cases, distributed through 
a series of years, and comprising a number of groups relating 
to various epidemics, and the best results they report are 1 death 
in II cases. A tabular arrangement of deaths was constructed 
for insertion here, but it was afterwards judged to possess too 
little interest to merit publication. 

4 — Sequelce — remarlcs iqwn character of and various forms of. l^o 
Y)[irt of the study of scarlatina is more interesting than that which 
concerns its sequelae. Do they depend upon a morbid process 
essential to the disease, or are they merely accidental conse- 
quences dependent upon some mismanagement, or other fortui- 
tous circumstances, connected with the primary attacks'? Do 
they principally follow the mildest cases, and therefore indicate 
that an energetic expression of regular symptomatic phenomena 
is a safeguard for the future of the patient! Does any one clini- 
cal form of the disease inflict upon the patient additional danger 
of sequehne — if so, what form is thus distinguished? These are 
questions of profound interest to the physician. Unfortunately, 
it may be, my report will not furnish suflicient evidence to justify 
satisfactory adjudication of either of these mooted points. Still 



42 



Original Conimmiications. 



it will bring* to the great garner of facts some additional glean- 
ings. We may therefore congratulate ourselves upon the aid 
we aftord to the ultimate elucidation of these points. 

The most common of the sequela3 reported is renal dropsy. 
This is not peculiar to scarlatinal epidemics here, but is prob- 
ably generally true. Meigs & Pepper found dropsy to ensue in 
31 of 274 cases, or 11.31 per cent. Steiner (Compendium of 
Children's Diseases; states that, ''The percentage of kidney com- 
plications in scarlet fever varies from five to seventeen." The 
percentage of all cases of sequelae, including those which were 
fatal with those which recovered, is 19.42. The percentage of 
cases of kidney complications is 11.24. The percentage of kidney 
complications in the gross number of cases of sequela3 is 58.76. 
This, however, does not represent the precise facts of the epide- 
mic as it respects the actual proportion of cases followed by 
renal dropsy. In one report, comprising an important number 
of cases, the reporter stated that an unknown number of his 
patients had suffered from renal complications as sequelae. Cases 
thus reported do not, of course, enter into computations appear- 
ing herein, except in respect to such points as are explicitly 
stated. 

Kextin point of frequency among the sequelae are affections of 
the cervical glands, It is to be inferred from the general tenor 
of statements of those reportitig, that in more than half of the 
cases in which inflammation of cervical structures occurred, ab- 
scesses resulted. In three instances the abscesses tollowed in- 
flammation of connective tissue, but in all cases they are repre- 
sented as having gland structures for their points of departure. 
One rei)orter indicates the parotid as most frequently the seat 
of adenitis. Another mentions the parotid and sublingual glands. 
One case is reported of abscess on both sides of the neck, which 
required to be opened, and which discharged a large amount of 
f(jetid pus. Cervical abscess was the cause of death in two in - 
stances. In one of the fatal cases it was "deep-seated, and 
commenced on the twelfth day." The mode of death is not more 
])recisely stated, but it is to be presumed that it took {)lace from 
exhaustion. Tiie other instance in which death was due to 
ab^icess, took place under my own observation and treatment. 
A child, aged two years, died of liemorrhage, presumably from 
slougiiing i)r()cess involving tlie facial artery, as that was the 
ileilicat considerable vessel to the ])oint of lilceratioiJ. A»s the 



1876J Bbmis^ —Statistics of Scarlet Fever in Neio Orleans. 43 



case had connected with, it rather an interesting- qnestion con- 
cerning its proper treatment, it ^YiiI be more particalarly con- 
sidered under^that head. 

Aural inflammations were very common sequelee. One excel- 
lent observer reports "abscess with perforation of both drums" 
in one case, and abscess with perforation of one drum in another 
instance, case of permanent loss of hearing has been re- 
ported, but several instances of temporary deafness are found 
among the reports. 

Discharge fi'oin the nares is frequently mentioned among the 
reports of sequelae. 

Vulvitis with purulent discharge is reported in two instances. 
These cases, with treatment adopted, will be again referred to 
under head of treatment. 

2>reuralgic affections, rheumatism, and joint inflammations, are 
mentioned by five reporters. One of this number mentions a 
case of synovitis, terminating in purulent accumulation. 

In two instances, fever of a typhoid type followed the primary 
attacks, resulting favorably. The reporters do not, in either 
of these instances, explain the probable causes of the continued 
fever. , 

Three deaths are ascribed to renal dropsy. In one of these 
cases the death is attributed to pericarditis. Four other in- 
stances of implication of cardiac structures in the scadatinal 
process, are mentioned in the reports. These were all endocar- 
dial; three involving the mitral valves, and one the semilunar 
valves of the aorta. 

Now, as to the inquiries made at the beginning of the discus- 
sion in regard to the character of sequelae. It must be admitted 
that nothing is reported in definite answer to the first of these 
inquiries. It is, in truth, a question whose solution involves a 
knowledge of the precise mode of action of the scarlatinal 
poison in and upon the human economy. There is a growing 
tendency in the profession to look upon scarlatina, as well as 
rlieumatism, as a disease whose unusually wide range of morbid 
action accounts for the great number of different organs impli- 
cated, rather than mere accidental metastasis. Entertaining 
this view of the pathology of scarlet fever, and placing the kid« 
neys within the range of morbid action, it would appear quite 
as natural for them to become points of localization of intense 
inflammation as the skin, or the throat. The proposition some- 



44 



Original Communications. 



[July. 



times advanced, that the kidneys are sacrificed by the mischief 
inflicted upon them as channels of elimination of scarlet fever 
poison, is scarcely tenable. A qnalified advocacy of the affirm- 
ative of these inquiries is in no manner inconsistent with the 
correctness of the pathological doctrines above stated. We are 
unable to interpret the laws which govern the mode of systemic 
diffusion of scarlatinal poison, but knowing, as all physicians do, 
the derivative effects of a local inflammation, w^e are well pre- 
pared to admit that x^atients suffering from intense eruption, or 
the anginose forms, are in some measure protected against 
nephritis. In ever^^ instance in which reporters have given in ob- 
servations in regard to these points, their .testimony is in perfect 
accord in regard to the relations between renal dropsy and mild 
primary attacks. Three cases of renal dropsy are reported con- 
sequent upon attacks so light that medical aid had not been 
invoked. Another reporter, who furnishes thirteen cases of 
renal dropsy, declares that ''all of them followed the mildest 
cases." 

The statistics upon which this report is based, justify these 
propositions : 

1. That simple and mild cases were more liable to renal com- 
plications as sequelae than were other forms of the disease. 

2. That anginose attacks Avere followed by sequelae in larger 
ratio than any other form of the disease — the sequelae being in 
these instances abscesses, otorrhoea, ozena, gangrenous condi- 
tions, and septic states of the system. 

3. That the death-rate of sequelae following anginose primary 
attacks, is greater by far than that of sequelae following simple 
attacks. 

More extended observations are necessary either to set these 
propositions aside, or to extend their authority. 

5 — Observations oj Age, Sex and Color. The reports bring con- 
siderable interesting matter to be arranged under this caption, 
in 420 cases, in which general statements were made respecting 
the ages of patients, 404 were reported as minors. Of the IG 
adults, one was 45 years of age, one 35, and one 30. The youngest 
patient reported was a child of 9 months. Of 83 instances 
in which the ages were reported with precision, the average was 
years and 5 months. Those interested in these figures will 
quickly understand that wherever a partial report of ages was 



1876] Bemiss — Statistics of Scarlet iever in New Orleans. 45 



made, extremes would Daturally attract tbe attention of reporters 
and be sent up for record. This would hold especially true of 
extremes in the direction of advanced age, since it is a recog- 
nized fact in medicine, that immunity from scarlatiuj^attacks < 
increases in direct ratio to increment of age. But, fortuuatelj'^ 
there is at hand a standard by which the accuracy' of these 
figures can be measured. A painstakiog and admirable worker 
in our profession has reported 55 eases, in each of which the age 
of the patient has been carefully noted. The average age of this 
group of cases is 8 years 11 months and a fragment. In another 
group of 12 cases observed by myself, the average age was 8 J 
years. To aid in illustrating the iufrequency of scarlatinal 
attacks in adult subjects, it is worthy of mention that of 5385 
deaths of persons insured in the iSTew York Mutual Life Insur- 
ance Company, only 10 were occasioned by scarlet fever. 

I am not willing to declare that the statistics returned in re- 
spect to ages of those attacked, are exponent of the actual 
standard of averages which more extended observations may 
exhibit. The average above shown is at variance with most 
authorities, in representing the standard at a more advanced 
^ period of life. This point is fully discussed by Thomas, Murchi- 
son, Meigs & Pepper, West, and Smith. Whatever may be the 
conclusions of some of the above named writers adverse to such 
a decision, I do not hesitate to express a belief that a high average 
age of attack in scarlatinal epidemics is proof of infrequency 
of epidemic visitation. Whatever maybe the degree of immu 
nity from scarlatina conferred by advancing years, no one con- 
tends that it is complete. Granting that it is not complete, the 
longer the intervals between epidemics, the greater must be the 
proportion of adults who are subjects ot attacks. 

Sex. Sex was noted in 1G7 cases of those reported. The re- 
sult was 78 males, 89 females. Two, or more, of the reporters, 
stated that males were more often subjects of attacks than lemales. 
It is quite probable, therefore, that a fuller report would have 
reversed the result of these observations. 

Color. This point was noted in 401 cases. The result was 
369 whites, and 35 colored. It is difficult to admit that 
these figures represent the true ratio of frequency of scarlet 
fever attacks in the white and colored races. The 5th of Dr. 
Minor's propositions is: "When scarlatinal epidemics occur 



46 



Original Communications. 



[July. 



within zones of comparative immunity, the disease attacks by 
preference the Caucasian race." Prior to the recent civil war, 
Kentucky and South Carolina were tlie only slave States which 
attempted to keep in operation, laws requiriug a registration of 
all births, marriages and deaths, occurring within their respec- 
tive borders. In the former State, the deaths ascribed to scarlet 
fever for the six years 1852 to 1857 inclusive, were 1754 whites 
aud 232 blacks. The census of 1850 gave Kentucky a population 
of 761,413 whites, and 220,992 blacks. If we base a computation 
upon this estimate of population, it will give one death from 
scarlet fever in every 434 whites, and one in every 951 blacks. 
It is unnecessary to explain to an experienced statistician 
that these figures do not claim .mathematical precision, but 
the}^ are sufficiently accurate to represent a fact that, for a 
l^eriod of six consecutive years the death-rate from scarlet fever 
was lower in that race than in the Caucasian race. The rate 
per cent, of mortality among the colored patients reported is 
11.42, nearly double that presented in the table of aggregates 
(page 4). This is quite in keeping with every candid statement 
regarding the ravages of acute diseases among these unfortu- 
uately circumstanced people, given over, as they seem to be, to 
politics, improvidence, crime, disease, and death. 

6 — Clinical Observations. It is to be regretted that full re- 
i:>orts have not been made under this heading. Whatever may 
be the erratic nature of scarlatina touching its symptomatic 
phenomena, or the influence of epidemic force in changing them, 
the study of its symptoms is one of deep interest. Every prac- 
titioner who has had any considerable experience in observing 
cases of this malady, has, no doubt, been often puzzled to know 
the significance of symptoms attending primary attacks. Symp- 
toms frightfully violent and sudden are very common manifesta- 
tions of the primary effects of scarlatinal poison, especially as it 
relates to the nerve centres. While those exceedingly malignant 
attacks which seem as it were to begin in death, are unquestion- 
ably aggravations of these disturbances of nerve function, many 
accessions of the disease marked by terrible nervous commo- 
tions result in recovery. The line which separates the two 
classes of cases is too indeterminate for prompt or positive 
de narcation. Trousseau once said that the rapid pulse of scar- 
hitina was woi th much as a diagnostic, and nothing as a prog- 



1876] Bemiss — Statistics oj Scarlet Fever in New Orleans. 47 



nostic. In a qualified manner, a similar remark may apply to 
those dreadful nervous commotions which distinguish attacks of 
this disease. 

In a number amounting to nearly or quite half of my cases, the 
first symptom was a sudden attack of emesis. Those who were 
sufficiently advanced to be able to report subjective symptoms, 
comphiined of cephalalgia and chilliness. One of my cases was 
inaugurated by a convulsion. It ran a favorable course and ter- 
minated without sequeloe. 

The highest record of temperature noted was 108° — the patient 
a female, 11 years of age. The observer adds that the "urine 
was albuminous throughout the case." The highest recorded 
temperature in the simple form of the disease is 105^, with a 
pulse of 168. Upon the next visit (presumably the next day), 
temperature 105°, pulse 160; third visit, temperature 102°, pulse 
134. A white female, eight years of age, had a temperature of 
105®, pulse 146. Another white female, aged 20 years, had upon 
three consecutive visits the following exhibits of temperature 
and pulse : 104.5°, pulse 136, 102.2-^, pulse 130; 102°, pulse 114. 

These were all simple cases. One reporter states that in the 
simple form the temperature is rarely noted above 103°. The 
same observer adds, that in the an gi nose cases the temperature 
sometimes rose, in severe cases, to 106°. *'In the malignant 
variety," continues the same excellent observer, ''the tempera- 
ture was not much elevated." Only one observation is reported 
w^hich indicates that a different condition, as it respects lebrile 
movement, is liable to be connected with the malignant type of 
the disease. A male negro, aged 28 years, died on the third day 
of the disease; the temperature in the axilla was 106.2°. 

1^0 special reports concerning the pulse have reached me other 
than the one recorded above. One reporter states that he had 
found that the pulse afitorded very unsatisfactory data concern- 
ing the patient's condition. 

From the general tenor of the reports, it is obvious that a 
majority of medical practitioners are accustomed to treat scarlet 
fever without examinations of urine, except in so far as relates 
to the quantity and gross- appearances of the secretion, unless 
Symptoms of uriT.mic poisoning, or dropsy, call for a different pro- 
cedure. A number of reporters make it a special point of men- 
tion that the renal secretion had been carefully watched from 



48 



Original Communications, 



[July. 



the beginning of the attacks, but few, however, seem to have 
subjected unsuspected secretions to a chemical test. 

One reporter has paid sufficient attention to the urinary 
secretion in the primary stages of the disease, to feel justified in. 
announcing the opkiiou that albuminous urine in the primary 
attack was a much more grave event than albuminuria as a 
sequel. This proposition is certainly sustained by analogical 
reasoning, if not by direct observations. In all other acute 
diseases iu which albuminous uriue is an early event, it is sup- 
posed to result from deperdition of the blood. Its appearance 
is therefore, to some extent, a measure of the devastation 
wrought upon that tluid by the presence of the morbid poison. 
On the other hand, albuminous uriue as a sequel may be re 
garded as being due to inflammatory processes in the kidneys, 
susceptible of resolution and cure, provided they are not so 
serious as to kill by complete arrest of kidney functions. Some 
very remarkable instances have been reported of tolerance of, 
and recovery from, the most extraordinary conditions of sup- 
pression anci perversion of urinary secretion. One of these 
cases had "albuminuria, convulsions, and temporary strabismus; 
totally unconscious five days; had general dropsy. These symp- 
toms commenced at the middle of the fourth week after the pri- 
mary attack, and lasted for ten days before permanent conva- 
lescence began. The urine was turbid with blood, and very 
scanty for seven days, during which time he lay in a state of 
lethargy, recollecting nothing which occurred, and at times it 
was very difficult to nourish him. The patient was a boy of 
about 10 years, of previous good health, and under the most 
favorable circumstances of hygiene and nursing." 

The most common attendants upon albuminuria as a sequel, 
were convulsions, cephalalgia, vomiting, dropsy, hematuria, and 
more or less suppression of urinaiy secretion. 

A very interesting fact is found in the report of one of the 
best observers in this city. This is the occurrence of a '^perio- 
dical increase of albumen," corresponding, in respect to inter- 
vals, with malarial manifestations, and, without doubt, due to 
the influence of that poison. 

Certain irregularities of clinical career are worthy of mention. 
Absence of eruption was noted in four instances. Seemingly 
true relapses were noted in two cases. One of these occurred 
under my own observation. B. L., white female, aged 7 years, 



1876] Be:hiss — Statistics of Scarlet Fever in New Orleans. 49 

seized, March 25th, with vomiting, chilliness, headache, and fever 
subsequently. On the 26th the rash appeared. The case ran a 
regular course, with symptoms sufficiently specific to render a diag- 
nosis absolute. The patient was dismissed convalescent on the 2d 
of April. On the 10th of the same month she was seized with a 
chill, followed by headache, fever, and severe sore throat. The 
punctated efflorescence over the fauces was so strikingly iden- 
tical with the appearances presented in primary attacks, that I 
exclaimed to her father — a medical practitioner himself — "If a 
genuine relapse in scarlet fever is a possible occurrence, here is 
surely one." On the 12th, patches of redness were observed on 
Various parts of the skin, but as the surface had been pretty 
generally frictioned with various embrocations, it could not be 
determined whether or not the redness was from this cause. 
The child had constant fever, and very great enlargement of 
the left side of the neck. On the 16th, an abscess in the left 
tonsil ruptured, discharging a considerable quantity of pus, after 
which some apjvarent amendment was- observed. During the 
primary attack, and up to the 19th of April of the second attack, 
no chemical examination of the urine had been instituted. It 
was sufficiently abundant, and gave us no reason to expect any 
abnormal constituent. On the 19th of April the urine became, 
diminished in amount to such degree that comi^lete suppres- 
sion was considered imminent. From the 19th until the 26th, 
the whole amount collected was by actual measurement 3xviiss. 
We estimated a loss of ^iiss, which would make the aggregate 
amount secreted ^xx. The urine was red from the presence of 
blood, and coagulated to a jellied mass under application of heat 
and acid. The microscope revealed great quantities of blood 
corpuscles, blood and tube casts. During the period of partial 
suppression, it was not pos.sible to obtain at any one time 
enough urine to fill the tube for measurement with theurinometer. 
After the secretion was resumed the quantity rapidly increased, 
until on the 5th day of May 61 ounces were passed, with a spe- 
cific gravity of 1005. May 6th — Quantity, 46 ounces, s. g. 1001. 
May 8th— 40 ounces, s. g. 1002. It is proper to mention in this 
connection, that on Saturday, April 22d, a colored woman, pre- 
viously nurse to the child, came to visit her. Some of the family 
observed that her face and eyes were much swollen, but not 
until the next day was it discovered that the nurse had just 
entered upon the stage of eruption of measles. Sunday night, 



50 



Original Communications. 



[July. 



April 30tli, the patieot had a severe chill, followed by fever, 
catarrhal symptoms, and the eruption of measles, Wednesday, 
May 3d. From all this terrible accumulation of complications, 
the patient gradaally emerged to complete convalescence. The 
urine continued to exhibit traces of blood and albumen as late 
as the 10th of Mslj. During the period of scanty urine, the 
patient suffered with frequent attacks of vomiting, much cepha- 
lalgia, and a precordial pain difQcult to account for; but with 
the exception of these rather ambiguous symptoms, no evideoces 
of ursemic intoxication were present. Sleep was quiet, the mind 
clear, and no convulsive tendency present. The only manifesta- 
tions of dropsy were puf&ness of the face and slight pitting about' 
the ankles. 

Some of the reporters have stated that in I he irregular cases, 
diagnosis had to be rested upon the pulse, temperature, and 
throat. 

7 — Treatment, All medical investigations and labors are at 
last directed to the same great and desirable end of curing, palli- 
ating, or preventing disease. I cannot do full justice to the 
work I have undertaken to execute, in respect to the i)ractical 
feature of treatment of scarlatina, or full justice to my collabo- 
rators, by epitomizing, or in any manner altering their reports 
touching this point. The reader will theretore find the remarks 
m full, of a large majority of those who responded to the circu- 
lars. In some lew instances no report was made under this 
heading; in several other rex)orts, the words "Expectant," 
"Symptomatically," or "Of the simplest form," conveyed in a 
forcible manner the mode of procedure adopted by the reporter. 

"On general principles, having always in view the reduction 
of the temperature and too rapid heart's action, the agents used 
have been the tincture of aconite with a gentle diuretic, sweet 
spirits of nitre, from the commencement of the attack. 

"For the cases of anginose forms of scarlet fever, the local 
application has been mild solutions of nitrate of silver twice a 
day, and hot poultices. In some cases, where the patient could 
gargle himself, I have used with very decided success a combi- 
nation of borax, chlorate of potassa, and rose honey — half a 
drachm of each to eight ounces mixture, avoiding always irritant 
doses." M. 



1876] BE3IISS — Statistics of Scarlet Fever in Netv Orleans, 51 



' Olostly expectant. In all, however, carbolized inunction three 
or four times a day was practised, till convalescence was well estab- 
lished. One part of acid to six of olive oil was used. In the 
only case of a serious character — as reported above (see page 
^7) — active purgation, diuretics, dry-cups over the kidneys, 
vapor baths, etc., were all resorted to at different times, followed 
by a quinine and iron tonic." L. 

"In mild cases gave laxatives, cool drinks, astringent and anti- 
septic gargles, inunctions with lard, and observed general prin- 
ciples of hygiene. 

"In severe cases, used cold spongings to the fullest extent the 
prejudices of the people would allow. 

"The case which died during primary attack (see page 
would not permit cold water treatment until 12 hours before 
death, when I instituted the cold pack, remained with patient 2 
hours, renewed the pack, and ordered its continued renewal 
every 2 hours until temperature should subside. As soon as I 
left the house the cold sheets were replaced by hot blankets. 

"Cases of simple albuminuria and anasarca were treated with 
warm baths, laxatives and diuretics (potass, nit., st. tether nit. 
and digital.). Convalescents were given quinine and tiuct. ferri 
mur. Where urgent symptoms supervened in sequelae, strong 
l^urgatives, calomel, jalap, ext. colocynth co., and even elaterium, 
were used; wet-cups along the spine, and blisters.'' P. 

"Tincture of iron and carbolic acid from the first— 2 to 7 drops 
of the former, and from ^ to 2 drops of the latter, every 3 hours. 

"Water, to which chlorate of potash had been added, was 
given ad Uhitum. 

"Wherever the temperature rose to 102", sponged freely with 
water acidulated with vinegar. Anointed the whole body after 
sponging, with carbolic oil. Had the room ventilated, and 
changed clothing when it became soiled. 

"For albuminous urine and dropsy, gave cathartics, applied 
wet or drj cups to lumbar region, and gave warm baths. 

"Where blood appeared in urine, continued iron and gave fld. 
ext. of ergot in from 10 to 20 minim doses. Two cases treated 
recovered rapidly'. 

"Careful and systematic nourishment, such as beef-broth, milk, 
milk punch, etc." ^ W, 



52 



Origin al Communications, 



[July. 



"Mercurial catliartie, if seen early in attack. Warm foot and 
genernl baths. Oleaginous inunctions." H. 

"Whenever seen in time, after the initiatory eruptive stage, 
I used small doses of chlorate of potash and tincture of chloride-? 
of iron, with happy effect. To facilitate desquamation, and to 
relieve the tension Jind harshness of the skin, I used sweet oil, 
castor oil, and skin of bacon. I also used quinine by inunc- 
tion. 

"I may add one additional case, which 1 saw only AJ^ter re- 
covery, yet suffering with some anasarca, which yielded to the 
potash and iron, and frictions with whiskey. 

^"I used small quantities ot bismuthi. subuit. by insufaation for 
t* relief of the catarrh, and simple washes of tepid water and 
castile soap for the ears.^ M. 

''In very nearly all my cases I used the chlorate of potas. for 
the throat, and used internally: R — Tinct. ferri mur. ^i, pot. 
chlor. 5i, acidi mur. ^i, tinct. digitalis ^i, aquae ^ii. M. 30 
drops every three hours in sweetened water, with nourishing 
diet and cooling drinks. I treated the renal sequelae with a 
mixture of bitart. potash and honey, and had a good result. I 
also used quinine in some of the cases, but my success seemed 
to be due to the first named mixture. In a case of diphtheritic 
sore throat, I used the inhalations of atomized tannin by the 
steam atomizer." D. 

"Expectant in every case, exce])t in such as were attended 
with kidney troubles, when digitalis, squills, and calomel were 
administered, until the secretion of urine was restored. Tonics 
of bark and iron subsequently administered. Applications of 
lard to the skin invariably soothed and disposed to sleep. Jabo- 
randi, administered in the case which proved fatal, produced 
profuse sweating but without relief to symptoms." L. 

"In the case of the gentleman aged 30 years, the febrile symp- 
toms were slight, but the soreness of the throat was marked. 
He had been for several days in close attendance upon his 
daughter, six years of age. Ten days after the subsidence of 
the throat trouble, slight but conpnuous fever returned, accom- 
panied within twenty-four hours by general anasarca, well-marked 
but not severe. Uiinu albuminous one-fourth. Under well- 



187G] Be3IIS« — Statistics of Scarlet Fever in iS^eiv Orleans. 53 



sustained catliartic and sudorific treatment, wet cups over kid- 
neys, foUoAved by a course of ferruginous tonics, patient made a 
good recovery. 

"Two lit'.le girls, sisters, aged 11 and 8 years, passed through 
the disease with the usual symptoms of fever and sore throat, 
but very mild in character. Three weeks after convalescence 
had commenced in the eldest, she was seized with high fever 
accompanied by severe pain in the hypogasLrium. The general 
features of the attack were those of a simple case of bilious 
fever, which responded most favorably to a free mercurial pur- 
gation. In two days convalescence was reestablished. During 
this last attack there was evidence, in the local i)ain and red- 
ness, of a decided vulvitis. AVhen this passed off, there com- 
menced a free purulent discharge from the entire mucous surface 
of the vulva and vagina. This lasted for six weeks, resisting all 
the methods of treatment common in such conditions. A mild 
solution of permanganate of potash did much good. Finally, 
the trouble seemed to yield to the local application of carbolic 
acid and tannin in glycerine (very weak), and the internal 
administration of cod liver oil and the ferrated elix. of calisaya. 
During the six weeks of the continuance of this trouble, there 
were two attacks of the fever in every respect like the first, ex- 
cept milder. 

'*It is peculiarly interesting that the sister, aged eight years, 
one month after her convalescence from the scarlet fever was 
seized exactly in the same way, with a fever like the first case, 
pain in the hypogastrium, vulvitis and vaginitis, purulent dis- 
charges following, and which continued two months. In this 
case, also, there were two relapses of the vulvitis, and other acute 
symptoms. When, in both of these cases, the local trouble had 
become chronic, it seemed to respond more favorably to the in- 
fluence of a tonic and nourishing course than to local applica- 
tions." H. 

*'As to the treatment ot scarlet fever, physicians often have 
peculiar notions of their own. But there is one thing that we 
all know, and that is, that it is a self-limited disease, running a 
certain course, accompanied and followed by two (if you will 
allow the expression ) other diseases — one diphtheria, the other 
dropsy. Although this is not always the case, yet we must, as 
far as ijossible, anticipate these complicutions, trusting to time 



64 



Original Communications, 



[July. 



aud nursing for the cure of the eruption and fever. This has 
been niy course for several years past. As to medicines, first a 
mild purgative, usually a few grains of calomel — 2 to 6 grains — 
with twice as much magnesia. If that does not act on the 
bowels, followed by castor oil or some saline purgative. Then, 
to moderate the fever, liq. ammonia, acetat., combined with 
spts. nitri and liq. morph., to quiet restlessness aud as mild 
diuretics. But the priucipal thing to be looked after is the 
ulceration of throat, for which I use tioct. fern cbloridi ^ii, 
l)otass. chlorat. ^i, and syrup 5ii. M. Teaspoonful every three 
hours, diluted with water when used, as a gargle and also taken 
internally. I resort to other treatment as the case and condition 
may seem to require^ not treating the name of the disease, but 
the condition present. If dropsy supervenes, small doses ot 
calomel, potass, bitartras with jalap, aud diuretics." W. 

'•The treatment was simple. IS'ot much medication was prac- 
ticed. I usually found constipation to exist in the incipiency of 
the disease, and gave a mild purgative; sometimes a smaU dose 
of calomel, if the tongue was furred and excretions checked. 
My object was to place nature, or the organism, under the most 
favorable circumstances, and in this way direct the attack or 
tide over it, sustaining the system in the most judicious manner 
possible. Some cooling febrifuge, controlling somewhat the cir- 
culation, during the height of the fever, together with greasy 
applications to abate the heat and lessen the itching, gave great 
comfort, and were probably the bust and safest anodynes. The 
throat affection — one of the chief local manifestations of this 
constitutional malady — was treated mainly with simple gargles, 
such as tincture of iron and chlorate of potash, lime water, tan- 
nin, etc. The cervical glands often suppurated, and especially 
the parotid and other posterior glands, frequently behind the 
mastoid muscle. The three that died from the sequel?e all had 
extensive suppuration of the glands, accompanied with a con- 
tinuous irritative fever of a typhoid type; also more or less 
rheumatism. It was sought to relieve the congested state of 
the kidneys, which produced the albuminuria and eftusiou, by 
equalization, as it were, and diversion; by moderate purgation, 
chiefly with cream of tartar, or something tantamount, and warm 
baths to encourage i)erspiration, at the same time alwaj's attend- 
ing sedulously to the nutrition to reorganize the blood, aud iu 



1876] BemisS — Statistics of Scarlet Fever in New Orleans, 55 



this way give an impetus, as it were, to the atonic state of the 
vessels and tissues. I found a line tonic to be, in this state, 
equal parts of Squibbs or Battley's ergot, and muriated tinct. of 
iron, given in frequent but moderate doses. All tlie cases of 
albuminuria and effusion recovered, and some after having con- 
vulsions from uremia.'^ B. 

"General plan of treatment was to keep patients warm until 
the setting in of convalescence. In a few cases, the bed was 
kept but 5 or 6 days, in others as many as 25 or 30 days. 
Allowed cool drinks (not ice), milk and broth diet. Had the 
skin anointed with leaf-fat, or French tallow, as long as there 
existed desquamation. 

'^Complications of lungs were combatted by kermes and 
brandy, and Alimentarj^ Elixir of Ducro. Gave quinine with 
slightest suspicion of malarial influence. I blistered once or 
twice in congestion of lung, and think to some advantage. 

Dropsical com jdications were met by a combination of digi- 
talis, scammony, and scillse, and I confess that I thought that 
with this combination, I could predict an amelioration of symp- 
toms in the 24 or 48 hours. 

At the offset of the disease, I have in a few cases given a 
vomit of ipecac and a slight purge, but do not advocate either, 
excepting to meet certain conditions, etc.'' * W. 

''In mild cases, saline laxatives; frequent sponging with tepid 
vinegar and water; cold acidulated drinks, either lemonade or 
vinegar. In the more severe cases I administered acetate of 
ammonia, with excess of the salt; acidulated drinks; an applica- 
tion to the throat of tinct. ferri mur. with potass chlor,; support 
throughout, beef-tea, milk, wine, and constant tepid sponging 
during febrile stage. V/ben desquamation began, inunction. 
Sponging resumed if fever returned. 

Eenal dropsy, of which thirteen occurred in my practice, 
readily yielded to copious purging with croton oil, followed by 
potass, bitart. as a diuretic, and the vapor bath daily, l^o sub- 
sequent impairment of health that I can discover has ever re- 
sulted." H. 

"Chlorate of potash in 5 to 10 grain doses every 2 or 3 hours; 
sulphate of quinine when the temperature became elevated, or 
previous to the period when once ascertained. Tincture of iron 



56 



Original Communications, 



[Jalj. 



in 5 to 20 drops doses, according to age, at the period of des- 
quamation. Tiuctare of iron and also cod-liver oil, to the case 
"with scarlatinous buboesj the swellings painted with the tinc- 
ture of iodine, in the hope of ahoriiug the same; linallj the use 
of the lancet, and poultices. 

"In the two cases ot dropsy from kidney affection following 
the scarlet fever, tinct. of iron in 5 to 10 drops doses every 3 
hoursj infusion of senra and manna in purgative doses; stimu- 
lating frictions to the back; diaphoretic drinks^ beet-tea, and 
light nourishing diet.'^ D. 

*'In mild cases, treatment consisted in mild cathartics and 
cooling drinks, with an aqueous solution of potassa sulphas _29ro 
re nata. Anginose case, active cathartic, and scarification of the 
tonsils and parts adjacent, in addition to *the treatment in mild 
cases. I can not speak too highly ot the cooling drinks, pro- 
vided the surface of the body is kept covered and warm at the 
same time." H. 

"During primary stage, liq. ammonia acetat. with tinct. aco- 
niti; the wet pack applied to the throat constantly, until erup- 
tion faded or the throat symptoms abated. 

"Inunctions of the skin during desquamation. 

"In the nnginose case, the ulcers in the throat were daily 
brushed with a strong solution of nitrate of silver. 

"On, the appearance of any throat trouble, chlorate of potassa 
was given internally. 

"In case of anasarca, acetate of potassa was given in infusion 



"In the four successful cases simple treatment was used, laxa- 
tives, diaphoretics, chlorate of ])otash, sometimes tincture of 
iron, gargles or washes of tincture of myrrh, alum, borax in solu- 
tion. In addition to the above, the iron excepted, there were 
used in the fatal case, quinine, calomel, oil of turpentine, carbo- 
nate of ammonia, and as a modifier of the throat affection, sul- 
phurous acid in the drink. In tliis case, as already stated, the 
only remedy that did any good w^as the sponging, which had a 
marked effect in reducing momentarily the temperature of the 
surface." M. 



of digitalis." 



H. 



"Treatment was necessarily varied according to circumstances. 



187G] Bmims— Statistics oj Scarlet Fever hi New Orleans. 57 



Generally, bowever, the bowels were evacuated at the outset, 
and a mixture containing quinine, chlorate of potash, and tinc- 
ture of iron, was given. When cinchonism would appear, tbe 
quinine would be omitted, but recourse would again be had to 
its use as soon as its unpleasant effects w'ould disappear. I 
was induced to give quinine steadily, because it seemed to me 
that, during the last three months, a distinctly appreciable mala- 
rial wave complicated my cases of scarlet fever. In many of my 
patients intermittent symptoms were clearly evident. Quinine 
was well tolerated, and I do not remember to have ever regretted 
its use. Attention was paid to diet — beef-tea, broth, milk, and 
alcoholic stimulants were used. Ice and iced drinks w^ere freely 
employed. Attention was paid to the condition of the skin. 
In cases of kidney trouble, the bowels were kept acting. Warm 
baths, dry cups, blisters, and other revulsive agents were brought 
into play. Various diuretics were employed. Among t4iese, 
some were directed to the heart and kidneys, and others to the 
kidneys alone. Milk was freel}^ used, not only as a dietetic 
agent, but also as a diuretic. The Bethesda water was used in 
three cases of kidney obstruction : in one instance it appeared 
useful, in the others no result w^as noticed. Iron, in various 
forms, was used in the different stages of the disease. In cer- 
tain varieties of kidney trouble, gallic and tannic acids, and 
ergot were given The throat troubles were treated in different 
ways. Chlorate of potash, tannic acid, tincture of iron, and car- 
boiate of iodine, etc., were employed. The carbolate of iodine 
seemed, in five or six cases, to be peculiarly successful. The 
foregoing remarks concerning treatment are necessarily general, 
as I have preserved no written notes of my cases. It is hardly 
necessary to add, that the condition of the skin was very closely 
w^atched, that exposure to cold was studiously avoided, and 
that the customary inunctions of the skin were carefully recom- 
mended. Frankly, however, I cannot say that I was satisfied 
with the results obtained from the lard inunctions.'' L. 

I have very few remarks to make in addition to the abstracts 
of treatment given above. I have given quinine to every patient 
to whom I was called during the stage of invasion. With every 
renewed opportunity of observing the effects of this drug upon 
the pyrexia preceding the eruptive stage of scarlet fever, my 
confidence in its favorable action is increased. Its th(^rapeutic 
effects appear to be manifold : an apyreticj a nerve tonic— per- 



58 



Original Communications. 



[July. 



haps lifting and toning up the system above the depressing 
influences of scarlatinal poison, as is conjectured in respect to its 
action upon the malarious constitution, and a modifier of the 
excessive waste due to the scarlatinal processes. An important 
objection to its exhibition is the liability to induce nausea. This 
can be obviated by using solutions in enemas of flaxseed emulsion. 
While it has not been my habit to continue it during the erup- 
tive stage, I have never failed to appeal to it as an anti- 
suppurative remedy in anginose ulceration or abscesses, and 
olten as a counter agent to atonic states of the system during 
convalescence. 

Another remark which I desire to make, relates to the treat- 
ment proper to institute in very grave cases of buboes. My 
usual practice is to resort to hot, moist applications, changed 
often, and applications of tinct. iodine once or twice daily until 
the irritation of the skin requires its omission. Twenty or more 
years ago, in deference to a popular belief in its efiicacy, I con- 
stantly used the slices of salt bacon which Smith praises so un- 
stintingly. At that time it certainly appeared to me good prac- 
tice. 

A question of importance relates to the surgical treatment 
of the lymphadenitis in its gravest forms. The highest autho- 
rities (Tbomas, Gee, etc.) advise to open as early as the collec- 
tion of pus can be determined. Every experienced practitioner 
understands that this advice is based upon the tendency to 
burrow which attaches to scarlatinal abscesses. But is it justi- 
fiable practice to make incisions into these hard tumors before 
purulent accumulations can be detected? This became a ques- 
tion in a case dying under my care from hemorrhage, and referred 
to on a preceding page. The tumor was so large and pressed 
so firmly upon the trachea, that death seemed liable to occur 
at any moment from suffocation. Deglutition was also extremely 
difficult. These symptoms were so urgent that the indication 
was in my opinion an almost imperativ^e one for an attempt at 
immediate relief. After leaving the patient, I accidentally met 
one of the leading medical gentlemen of this city, and stated 
the case to him, inquiring at the same time how it was possible 
for me to lessen pressure around the tumor by draining it of ex- 
trav^asated fluid and yet avoid the risk of dangerous hemorrhage. 
He suggested aspiration with a hypodermic syringe. Upon re- 
turning with the intention of attcmi)ting this mode, I found the 



1876] Bemiss— Statistics of Scarlet Fever in New Orleans. 59 



symptoms greatly aggravated, and the tumor so brawny and 
resisting that I feared to waste further time by using the syringe. 
I at once passed a sharp pointed bistoury into the tumor, mak- 
ing a deep incision. Quite a considerable quantity of bloody 
serum, and shreddy material escaped. Warm poultices were 
again applied, and by the next morning the size of tumor was 
reduced, aud the child's respiration and deglutition were better 
pertormed. The puncture w^as made on Friday, Dec. 31st, 1875. 
On the morning of Wednesday, Jan. 5th, one side of the incision 
looked of an ash color, and tearing hemorrhage, I explained my 
fears to the parents of the patient, and ordering a solution of 
perchloride of iron and some lint, gave instructions what course 
to pursue in case the apprehended event should occur. During 
the ensuing night sudden and profuse bleeding took place, re- 
sulting fatally in less than two hours. 

I have prescribed ergot for the bloody and albuminous urine 
of nephritic complications. The prescription used was Squibb's 
fluid ext. ergot, .^j; dilute sulphuAc acid, ^ss; syrup poppies, 
or syrup blackberry, ^viss; teaspoonful every 2 to 4 hours. 
To this prescription I have occasionally added, gallic acid, grs, 
xij to xvj. While I cannot positively declare that curative 
effects followed these prescriptions so uniformly as to justify the 
assumption of a relation between them, I am yet so well satisfied 
with results that I shall continue the prescription. 

The propositions in reference to treatment may be stated as 
follows : 

1. We know neither an antidote to, nor a sure eliminator 
of, the scarlatinal poison, therefore our safest treatment is 
"symptomatic," or "expectant." 

2. The symptoms which most frequently demand our care in 
the simple form, are excessive temperature and excessive skin 
inflammation. For these, the cold douche, cardiac sedatives, 
and inunctions afford the best therapeutics. 

3. The anginose variety requires additional treatment by the 
local application of astringents, alteratives and disinfectants to 
ulcerated surfaces, proper attention to lymphadenitis, and espe- 
cially those tonics and blood depurants which prevent or cure 
septic states of the system. 

4. The treatment of the malignant form of scarlet fever should 
be varied to meet the varying conditions present. One reporter 
mentions that the highest temperature noted was in a malignant 



GO 



Original Communications. 



[July. 



case; another states that the maligDant cases observed sliOTved 
lovrer records of temperature thau other forms of tlie disease, 
I am satisfied that both were strictl^' accurate in their observa- 
tions. Trousseau's remark, ''that scarlatina, especially when its 
form is malignant, is of all diseases that in which the tempera- 
ture of the body rises to the highest point," should not be under- 
stood to be applicable to all cases of the malignant form. While 
our choice between the cold douclie or sponging, and w^arm 
baths, may be governed by the heat of the surface, there is good 
reason to believe tliat upholding measures of treatment are 
})roper for all malignant cases. Quinine, carb. ammonia, small 
opiates, alcoholic stimulants and forced nutrition, are the means 
of cure usually most beneficial. 

5. Scarlatinal dropsy is amenable to cure by hydragogue? 
purges, diuretics, diaphoretics, and blood restoratives. 

6. Severe sore throat in scarlet fever is liable to be followed 
by gangrenous, suppurative, or septic processes in the system, 
attended by low forms of secondary fever, and requiring local 
and general measures of treatment, w^hich, however carefully 
varied to meet x^^i^i'ticular conditions present, yet often fail to 
care. The sequelse of the angiuose form are therefore more 
serious as points of treatment than renal complications. 

8 — Gontagium; Inciihative Period; Freventive Meam; General 
Kemarks. It is to be admitted that the degrees of intensity 
of all epidemics — whether this intensity related to the sympto- 
matic violence of their attacks, or to the universality of the 
diffusion of their germs, should not be regarded as matters of 
mere chance, but rather as being determined b\^ laws sufii- 
ciently fixed to render them sooner or later, subjects of remu- 
nerative study. Scarlatina exhibits extraordinary eccentricity 
in all of its leading features, but in no one essential character- 
istic is this more strikingly shown than in the anomalous beha- 
vior of its contagium. xlt one time it appears to be so unsparing 
in its sweep that very few of the unprotected escape. At other 
times, its contagium exhibits so little of this fierceness that 
comparatively few attacks result, whatever may be the apparent 
amount of exposure. The introduction of the word "apparent'^ 
in the last sentence implies a want of knowledge of those condi- 
tions which give life and activity' to scarlatinal disease germs. 
If they possessed as much uniformity in regard to repro- 



1876 1 Bemiss — Statistics of Scarlet Fever in JSfew Orleans. 61 



diiction and activity as the variolar poison, we would be 
able to predicate some rules respecting liability to attack after 
exposure. Consequently we could then speak with more cer- 
tainty of greater or less degrees of exposure. But there 
is nothing of regularity in scarlatinal infection. Often we 
observe one case only, occur in a large family, or children's asy- 
lum, although no means are used to prevent its spread. Again, 
we see it over-leaping all the preventive measures with which 
we seek to surround our })atieuts for the protection of the well* 
I think it a reasouable inference that this eccentricity is due to 
circumstances affecting the contagium, rather than to any cir- 
cumstances or conditions which may be supposed to atfect the 
human system so as to alter personal receptivity of the poison « 
A subtle contagiusn, which undoubtedly is endowed with attri- 
butes resembling those of organized substances, may show widely 
differing states of activity and virulence, subject to atmospheric 
or telluric influences not susceptible of formulation in our present 
state of knowledge. 

No report has been made of observations tending to show the 
period at which a scarlet fever patient is most likely to infect 
persons brought within range of infection. Kor have any facts 
been furnished, which indicate that the scales of the desquama- 
tive stage are either chiefly or partially vehicles of communica- 
tion. No doubt, Thomas expresses truth when he says "it may 
be presumed that the contagion enters from the blood into all 
the secretions and excretions of the patient.'^ 

In a crowded city, with scarlet fever epidemic among its entire 
population, reports in regard to the incubative period have all 
the liability to fallacy which must arise from the indefinite mul- 
tiplication and diffusion of infecting foci. I venture, however, 
to report from my own practice, two cases in which pretty fair 
opportunity was afforded to observe the periods of incubation. 

0., aged 13 years, spent Saturday, January 29th, at the resi- 
dence of four children who had never had scarlet fever. The 
disease had fur some time been prevalent in O.'s family, and one 
case was convalescing at the time of her visit. At dinner she 
occupied a chair situated between two of the unprotected chil- 
dren— M., aged 13, and H., aged 8 years. On Wednesday, Feb. 
2d, H. comphiined of chilliness, headache, nausea and vomiting, 
and sore throat. The rash appeared on the following day, and 
a very severe example of the anginosc form of the disease 



62 



Original Communications. 



[July. 



resulted. The other chikireu present at the dinner escaped 
attacks. No other case occurred in H.-s family, although the 
only preventive measures were exclusion from H.'s chamber. In 
this case, about 86 hours elapsed after exposure before symp- 
toms manifested themselves, while the non-eruptive stage lasted 
some 20 hours. 

B. L., aged 7 years, lost a little brother from pneumonia com- 
plicating hooping-cough, March 21st. She attended the funeral 
March 22d. Taken ill on the 25th; eruption appeared on the 
26th. M. L., aged 4 years, was suffered to enter at will the 
chamber in which B. L. was confined, and no measures were 
employed to prevent infection. M. L. remained free from attack 
until April 23d, when scarlet tever was inaugurated with a chill 
and convulsive seizure. On another page of this rei3ort, the 
reader will find that B. L. suffered under symptoms strongly 
indicative of a true second attack of scarlet fever. If M. L. 
contracted the disease from B. L., we must assume, either that 
the germs trom the primary attack infected lier, which would 
indicate an incubative period of 20 days or more, or that the re- 
lapse produced the infecting material, which would imply an in- 
cubative period of about two weeks. Thomas reckons the incu- 
bative period of scarlatina at an average ot from four to seven 
days. My own observations teach me to look with distrust upon 
histories of cases claiming a period of incubation longer than a 
fortnight. 

No cases were reported of parturient females suffering under 
attacks of the epidemic, nor any instances of extraordinary per- 
sonal liability to be affected by the poison. 

The measures of prevention most often resorted to were isola- 
tion and the disinfection of rooms and bedding occupied by 
patients. Several cases were alluded to in which no spread of 
the disease occurred, although neither isolation nor any other 
means of prevention was resorted to. The following instance 
will illustrate the above statement. The family of H., a German 
baker, comprised three children, aged respectively 4 years, 2 
years, and 3 months. The child aged 2 years was attacked 
December 22d. I saw it for the first time on the 24th, when an 
abundant rash covered the surface. The child died on the 14th 
day of the disease. The other children were kept in the same 
room with the scarlatinal case, and yet neither one suffered an 



1876] B-EMiBS— Statistics of Scarlet Fever in Neic Orleans. 63 



attack. Instances of this sort are unquestionably sometimes 
made to contribute in bestowing upon belladonna its totally 
unmerited reputation in preventing scarlatinal attacks. One 
reporter sends up a case in which he administered belladonna, 
to a child as a preventive, and naively added that it "turned 
out to be the worst case he had." 

General Remarlcs. In the admirable compendium of Children's 
Diseases, by Steiner, we find the following paragraph : "A very 
dreadful kind of scarlet fever is every now and then met with, 
where the child succumbs almost directly to the most violent 
symptoms, without the forewarning of any prodromata. These 
cases sometimes run their course from beginning to end in thirty- 
six or forty-eight honrs, almost even before the eruption has 
appeared, the only symptoms being vomiting, loss of conscious- 
ness, coma, violent delirium, or convulsions, with a most abnor- 
mal and continuously high state of the temperature. They are 
generally the forerunners of an epidemic, and are not unfre- 
quently seen in children who are very healthy.'^ On Saturday, 
April 8th, I was summoned to visit G. H., a remarkably healthy 
male child aged two years. It was 12^ p. m. vrhen I reached 
the i)atient. The history given me, was that the child had arisen 
in x^erfect health and partaken of a hearty breakfast with his 
usual appetite. After this meal he had played with various 
members of the family, when about 10 o'clock he suddenly grew 
pallid and commenced vomiting. The emesis persisted until 
after my arrival and the administration of a dose of calomel, 
prepared chalk and opium, and the application of a spiced poul- 
tice over the epigastrium. At the time of my visit, the child had 
high fever, a rapid pulse, and red cheeks. He took little or no 
notice of anything said or done in his room. His mother stated 
that he complained of his throat when first seized with his ill 
fit, but no evidence of inflammation could be noted either inter- 
nally or externally. In the course of the afternoon, several 
small alvine dejections occurred, fluid in character, seemingly 
due to the calomel. Quinine was given under a fear that malaria 
might have caused the attack, although the entire absence of 
prodromes, and the fast pulse, and rather florid surface, led me 
to make a probable diagnosis of scarlet fever. Daring the night 
convulsions were so strongly threatened, that I prescribed bro- 



64 



Original CommuniGations. 



[Jaly. 



inide of potash with a small opiate. This did not prevent their 
occurrence at about 6 o'clock a. m. of Sunday. Dr. T. G. Eich- 
ardson now saw the case with me, but the child soon fell into a 
semi-comatose state, and death ensued at 2J p. m. of the second, 
day of illness. The indications of an eruption were so indefinite, 
that I unhesitatiuglj' rejected all those appearances which were 
pointed out by the very intelligent nurses who had care of the 
child. 

A point in the history of this case is proper to be men- 
tioned. In a house adjoining that of G. H., lived the family of 
B., which comprised several children unprotected by previous 
attacks of scarlet fever. On Wednesday, 5th of April, G. H. 
visited the family of B., and plaj-ed with the children, more 
especially with one just his own age. This child was seized with 
sudden illness on Wednesday night, and died in about 24 hours. 
The fact that the children had been associated so shortly pre- 
vious to their sudden deaths, led to suspicion of accidental 
X3oisoning. There were no symptoms present which I could ac- 
count for by imputing them to any ijoison, or combination of 
poisons, likely to be within reach. I therefore requested a post- 
mortem, which was granted in so far as it related to the abdo- 
minal cavity. This was done by Dr. Eichardson and myself, 
Monday, April 10th. l:^"o thing was discovered, either as it re- 
spects the solids or the fluids, which accounted for death. The 
B. child was attended by Dr. P. 0. Boyer, who informs me that 
no symptoms of scarlet fever had been manifested in any mem- 
ber of the family before, or after the child's death, although 
several of the children, directly after these events, had fevers 
distinctly malarial in their character. At the time of these 
deaths, scarlet fever was present in one or more families in the 
same square. I do not venture to diagnose this case as one of 
scarlet fever, and it does not figure in the enumerations of this 
report. I cannot, however account for the death in any satis- 
factory manner, other than by referring it to an overwhelming 
toxaemia from the materies morbi of that disease. 

To illustrate yet further the analogy between this case and 
some which occurred in this city during a former epidemic of 
scarlet fever, I will copy here the account of instances of sud- 
den death from malignant scarlet fever observed by Dr. F. 
Downer.* 



See N. O. Med. aiul kSurg. Journal, vol. iv., p. 5u2. 



1876] BemisS — Statistics of Scarlet Fever in ISfeiv Orleans. 65 



Report of several Cases oj Scarlet Fever. By F. Downer, M.D., oi 
New Orleans. 

Case I. — Dec. 12th, 1847, called by appointment, at 4 p. m., 
to prescribe in a chronic case, for a member of a large family. 
Before leaving, I was requested to look at their son, a boy of 
seven years, who for several days had been laboring under what 
appeared to be a bad cold, but on this day he seemed so much 
worse, they began to feel uneasy. 

I found him with a high fever; great difficulty in swallowing; 
mind confused and wandering; tongue dry, and loaded with a 
thick dark coat; teeth covered with sordes; with a slight erup- 
tion on the face and neck, of a livid hue. I at once pronounced 
it to be malignant scarlet fever of a typhoid type Ordered cold 
elusions to the head and face; a gargle ot infusion of capsicum, 
alternated with one of sage tea, houc-y and alum. Tens grains 
calomel, with four of ipecac, in four powders, one to be given 
every three hours till it operated; to be followed with flaxseed 
tea, or barley water, acidulated with lemon juice. 

13th. Skin hot and dry; oppressed breathing; countenance 
haggard; great restlessness, with delirium. Owing to the un- 
manageableness of the patient, the directions had been but 
slightly fulfilled : a part of two of the powders had been given, 
and brought away two discharges of very dark offensive matter. 
Ordered one grain tartar emetic to an ounce of water, a tea- 
spoonful every half hour till it acted as an emetic, with volatile 
liniment to tiie throat. He vomited slightly, but so great was 
the difficulty of deglutition that but little more was done; deli- 
rium, with frequent convulsions daring the night, and on the 
morning of the 14th he died from suffocation. 

Case 2. — At daylight on the morning of the 17th, I was called 
to visit an older brother of the deceased, aged nine years. He 
had appeared well up to the day previous, when he was engaged 
the greater part of the day in shopping with his mother. Game 
home late, and ve;y much fatigued, but ate an unusually hearty 
dinner of vegetable soup, meat and potatoes, which in an liour 
or two he threw up, and without making any complaint, soon 
after retired to bed, When I saw him, he was laboring under 
short, quick, and anxious breathing; pulse rapid, and vibratory; 
increased heat of the head, whilst that of the body was but little 
above the natural standard. There was uneasiness of the throat, 
with hoarseness and a slight enlargement of the tonsils: great 
intolerance of light, mind confused and wandering. 

Gave an emetic of antimonial wine, which caused him to eject 
a large quantity of tenacious, ropy mucus, with decided relief. 
8 o'clock. — Ten grains calomel with five of ipecac to be followed 
with flaxseed lemonade; cloths wrung out of cold vinegar and 
water to be constantly applied to the head. 



Original Communications, 



12 o'clock. The bowels moved; foeces of a light clay color, 
ami highly oftensive. Warm sage tea, continue cold applica- 
tions to the head. 

At three o'clock I was sent for in great haste, as the boy was 
believed to be dying. On arriving, fouiid him almost in a state 
of collapse— pulse weaker and quicker; had had two discharges 
since I saw him at 12 o'clock, the last involuntary, and in the 
highest degree offensive. Ordered weak brandy toddy, a starch 
injection with laudanum, and dispatched a messenger for my 
triend Dr. Harrison, The heat of the body being grea;tly dimin- 
ished, with the pulse at the wrist quite imperceptible, we applied 
sinapisms to the abdomen, ankles and wrist: gave sub-carbonate 
of ammonia alternately with the brandy toddy. 

At 6 o'clock we again met; he w^as now insensible to surround- 
ing objects^ great jactitation, constantly tossing his arms about,, 
and moaning. These symptoms seeming to indicate a high 
degree of gastric inflammation, the idea ot poison suggested 
itself to the mind of Dr. H.; but on pressure of the abdomen 
and over the region of the stomach, not the slightest evidence 
of tenderness or pain did he evince, nor bad he from the com- 
mencement, as I had frequently examined these parts, and asked 
the question -while he was able to answer. He now rapidly sank 
till death closed the scene, during a convulsion, at 8 o'clock, it 
being but little over twelve hours since I was called to see him.. 
An examination of the body was not permitted. 

Case 3. — Dec. 23d. Was called at 7 o'clock^ a. m., to see a^ 
daughter of five years; found her with slight fever; frequent,, 
but not very full pulse; dry, brown tongue; some swelling of the- 
throat, with slight redness uf the tonsils and difficulty of breath- 
ing; bowels constipated. Prescribed senna and manna, flaxseed 
lemonade; vol. liniment to the throat, with a flaxseed poultice. 

11 o'clock. The bowels had been moved once freely, foeces- 
light and oftensive with scybala and undigested food. Another 
discharge very copious, same color, without scybala or food,. 
Ordered twelve leeches applied to the throat, and to take a tea- 
spoonful of the following mi:i:tuic every two hours— 

Muriate ammonia, ^jjs,, 

Emetio tartar, 1 gr., 

Ext. glyc, 3j, 

Aqua dist., ^iv. 

7 o^clock. Leeches had drawn well^ had had another passage 
of the same kind; kept up the mixture, with the same drinks,, 
and frequent sponging of the head and face with vinegar and 
water. 

21th— 8 o'clock. Much better, would not take any more medi- 
cine; during the morning asked for tea and dry toast, whicli 
was granted. 

25th. Much improved; the rash well developed; tongue clean^, 



1876] Bemiss — Statistics of Scarlet Fever in New Orleans. 67 



with papilla very elevated; bowels costive; order senna and 
manna; to be kept quiet. From this time she improved rapidly. 

Wliile I regret that a post-mortem examination was not 
allowed in the second case, I am satisfied, on a review of all the 
sym})toms, that this was a case of a regular congestive form, 
and that the head, and not the stomaijh, was the part most 
affected. The ten iency to assume the typhoid type so early in 
the coarse of the disease, can only be accounted for by the pecu- 
liar contagion to which he had been exposed; and this, as Dr. 
Good remarks, "under a depressed state of the living power, 
whatever be its cause, whether a want of cheerful warmth, 
cheerful passions, cheerful food, or cheerful and regular habits, 
typhus is often more likely to take place than any other species 
of fever. But when febrile miasm, produced by a decomposition 
of efduvium from the living bod^^, exists in a cooperation with 
these, it is almost impossible for an individual to escape; as the 
miasm thus generated has a specific power — a power beyond all 
other febrile causes whatever, of lowering still farther the vital 
energy as soon as it is received into the system, and thus of 
confirming the tendency to this peculiar type." In this instance, 
the boy suffered much during the last hours, and after the death 
of his little playmate; he had slept in the same bed with him, 
until within two days of the death of the latter — was taken sick 
immediately after a long and fatiguing walk, the hearty dinner he 
ate assisting still more to depress theexhausted vital po'^ers. The 
weather for two weeks preceding had been unreasonably warm 
and rainy; the thermometer, for about ten days, had ranged 
over seventy degrees, while the location was damp and low. All 
these causes acting on an existing predisposition; hence the 
sudden overpowering shock, ui^der which the system gave way 
in so few hours, and while the medicine was apparently doing- 
its offices kindly. Dr. Armstrong is the only author I know who 
describes this form of scarlatina. He says, "the subjects of this 
modification are for the most part suddenly attacked." "Some- 
times they at ouce sink as if overcome by a sudden shock, and 
lie in a state of confusion and oppression, without making much 
complaint." "The mind at first alarmed, confused or dejected, 
soon becomes disordered with delirium, or an indifference to 
surrounaing objects, and a stupor succeeds under which patients 
finally expire." 

In two other very severe cases of scarlatina anginocua which 
I treated a week before, both the parents suffered from severe 
sore throat, attended with febrile symptoms, but no eifiorescence 
of the skin; ai^ adult member gf the first family labored under 
soreness and swelling of the fauces, unattended with febrile 
symptoms, thus showing the [)rotean nature of the disease, and 
the degree of virulence it assumes according as it is met by a 
predisposition, or otherwise. As regards my experience, scarlet 
fever is most to be dreaded of any of the diseases incident to 
childhood, whether considered in its immediate consequences or 



68 



Original Communicatiom. 



[July. 



as regards its results. As Dr. Francis observes, it is one for 
which we have no prophylactic; and in this climate delay in re- 
sorting- to immediate remedial measures is so often fatal, that 
active treatment should be couimeoced from the first suspicion 
of the complex form of the disease;, and then^ alas !' the bills of 
mortality tell with what success. 

In conclusion, I sincerely thank those of my confreres who- 
have kindly given aid and encouragement to this mode of study- 
ing disease. Whilst I shall not venture to speak of it as a com- 
plete success, the results appear to me sufficiently satisfactory to- 
justify a further prosecution of the undertaking:. I shall there- 
fore issue new blanks within a few days, and again request the- 
assistance of my professional brethren in studying some other- 
disease in a statistical manner. In the mean time, I invite from 
those concerned the most free and critical couimeut in regard to- 
the manner in which I have discharged the duties of a reporter.. 
If I voluntarily undertake to represent the views and observa- 
tions of my brethren in regard to any professional subject, I 
shall not seek to shun responsibility for the proper execution of 
these trusts. 

I regret that a table of errata must be appended to the report, 
but absence from home during the time when the first forms 
were worked off, occasioned several errors so important as to 
demand notice. 



Eretata. 

Page 37, 10th line, from for " read 3.62. 
Page 38 (Table), 16.54 should be inserted between 46.40 and 
30.66. 

Page 40, for "attack" read attacks. 

Page 42, fifteenth line from bottom, for "all cases" read all 
other cases. 

Page 45, fourth line from top, for "scarlatina" read scarlatinal^ 



LIBRARY OF CONGRESS 



















ll 




li 





021 623 836 9 ^ 



Hollinger Corp, 
pH 8.5 



LIBRARY OF CONGRESS 


III 













021 623 836 9 ^ 



HoUinger Corp. 
pH 8.5 



